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Much of the medical home model is predicated on a relatively stable population that can access regular care at a single network of providers.  So how can this model effectively transfer to a mobile population?  This crosswalk is meant to assist centers to incorporate the needs of migrating patients into their PCMH. Each of the six standards are listed with the factors required for NCQA recognition. Recommendations for addressing the factors in migrating patients are included, along with resources available through MCN. Meaningful Use and Core Measure content is noted as it is also present.

Clinicians can use this form to collect information from patients about their prior use of non-traditional or alternative care providers and medications.

Health centers can also adapt the form and/or incorporate into their EHR.

PCMH Standard 2 Element B: Clinical Data, Factor 9: List of prescription medications with date of update for 80% of patients.

PCMH Standard 3 Element D: Medication Management, Factor 3: Provides information about new prescriptions to more than 80% of patients.

PCMH Standard 5 Element B: Referral Tracking and Follow-up, Factor 5: Asks patients about self-referrals and requests specialist reports.

This is the first of several resources MCN is developing to aid health centers in addressing the unique healthcare needs of migrant patients within the Patient Centered Medical Home. In addition, MCN is developing tools and resources health centers can utilize as they seek PCMH recognition.

Open Access means that patients can get same-day appointments for acute care needs and rapid access to routine care needs. This resource describes what Open Access looks like for migrant patients.

NCQA Standard 1: Enhance Access and Continuity; Element A: Access During Office Hours

Family Psychosocial Screening also assesses a number of other risk factors for developmental and behavior problems. These include frequent household moves, single parenting, three or more children in the home, less than a high school education, and unemployment. Four or more such risk factors including mental health problems and an authoritarian parenting style (observed when parents use commands excessively or are negative and less than responsive to child initiated interests) is associated with a substantial drop in children's intelligence and subsequent school achievement . In such cases, children should also be referred for early stimulation programs such as Head Start or a quality day care or preschool program. 

PCMH Standard 2, Element C: Comprehensive Health Assessment, Factor 2: Practice conducts and documents a health assessment including family, social, cultural characteristics.

Much of the medical home model is predicated on a relatively stable population that can access regular care at a single network of providers.  So how can this model effectively transfer to a mobile population?  One of the key elements needed is a more expansive vision of a medical home beyond a single geographic location.  This session will explore strategies to create a patient centered medical home for patients on the move.  The presentation includes an update and overview of MCN’s Health Network to manage critical health care issues such as infectious disease, Cancer, Diabetes and Pre-natal patient navigations.  The content highlights innovative promising practices in the creation of patient centered medical homes for migrant patients.